I was recently interviewed for a Medscape article about maintaining professional boundaries, entitled, When Patients Try to Seduce Doctors. It’s a relatively short piece and, though I was misquoted a little, it has some good information about the doctor-patient relationship and the importance of establishing and upholding appropriate professional boundaries. Check it out.

The Washington Post ran an article about a Tel Aviv University study of the effects of physicians’ disruptive behavior on patient safety. As discussed in previous posts, there is a clear link between disruptive behavior among physicians (and other professionals) and negative patient outcomes. The coworkers who are often the target of or witness to disruptive behaviors typically avoid their disruptive colleague. This avoidance is understandable but can significantly break down communications among treatment teams. When the different members and disciplines within a treatment team do not candidly interact with each other bad things happen: nurses don’t confront physicians’ mistakes, wrong-sided surgeries occur, etc. Disruptive behavior must be taken seriously and assertively addressed by leadership.

As a psychologist, this is no surprise to me, but medical schools and physicians’ residency training programs are concluding that empathy (understanding the patient’s perspective and effectively communicating that understanding to him or her), in fact, matters quite a bit.

Programs Aimed At Equipping Doctors With Empathy See Yielding Results.

In a nearly 1,650-word piece, Kaiser Health News (3/13) reports efforts to teach doctors about empathy is yielding results, citing the example of a Jeremy Force, a first-year oncology fellow at Duke University Medical Center. Force put into practice what he learned in “‘Oncotalk,’ a course required of Duke’s oncology fellows,” consequently earning praise from a patient suffering from breast cancer. The article notes “clinical empathy was once dismissively known as ‘good bedside manner’ and traditionally regarded as far less important than technical acumen.” However, “a spate of studies in the past decade” has come to the conclusion that “it is no mere frill,” and empathy “is considered essential to establishing trust, the foundation of a good doctor-patient relationship.”

I often hear from my patients how busy they, their careers and their lives are. Occasionally, their impatient, abrupt or frankly disruptive behaviors at home or at work are blamed upon simply not having the time to slow down to deal with others more gently or explain things more patiently. In their haste they find themselves bogged down by having to deal with others’ hurt feelings, confusion or seeming incompetence; this, of course, only makes matters worse as they then have to apologize, remediate the situation or reexplain things, all in the context of the limited resource of time.

On the way into work this morning, I heard a great piece on NPR about “scarcity.” The piece compared how poor people often mismanage money (e.g., buying lottery tickets, renting large tv’s, etc) to how busy people often mismanage time. Both groups of people have trouble managing their limited resource. I found this fascinating and directly relevant to many of my patients. I do a lot of psychotherapy and remedial coaching with physicians, other healthcare professionals and executives, and I find that nearly all of them are truly quite busy and they work very demanding schedules. But it never ceases to amaze me how so many of these brilliant people struggle to appreciate the need to devote time to their interactions with other people. I’m not a huge fan of Steve Covey’s “7 Habits” but I love the one where he says, “with people, fast is slow and slow is fast.” You can’t rush relationships. You can’t speed up communications beyond a certain threshold. Instead we need to devote sufficient time to our interpersonal relationships, to nurturing them and communicating effectively within them.

My friend and colleague, Mike Plaut, has another paper out (actually it’s still in press) in the Journal of Health Care Law and Policy. Mike’s writing is great – almost conversational – so I always enjoy reading his stuff. In this paper he describes the work he’s been doing for years at the University of Maryland’s Medical School with health care professionals who act out sexually with patients. Similar to the work I do with disruptive professionals, Mike works individually with physicians and other providers rather than working with groups, and he tailors his interventions to the individual. Now, in contrast to most of my work, Mike holds tighter to the role of the academic advisor than therapist or even coach, as he guides the professional through the relevant literature and has them write a paper about the reason for their referral to him. I typically blur the boundary between coach and therapist as I believe there are more similarities between remedial coaching and psychotherapy than differences, and I have found this to be an invaluable approach to my work with physicians, psychologists, nurses, other healthcare providers and other professionals who have gotten themselves into hot water at work, usually because of interpersonal problems.

I just found an interesting article that is still in-press about fitness for duty evaluations for physicians. A significant part of my practice is devoted to assessing and addressing issues related to physician (and other professional) impairment and disruptive behavior. Much of the consulting I do is with licensing boards, professional associations, hospitals and practices, so this article was of great relevance to my practice. One of the findings that I was particularly pleased to read was that the authors noted that of the physicians they evaluated, most of the time those referred for “disruptive” behavior were assessed as being fit for duty. This is consistent with the majority of my findings; however, this should not be misinterpreted as saying that there are not very significant potential risks and dangers of disruptive conduct within the workplace. In fact, this is precisely what makes it so difficult to perform fitness for duty evaluations for disruptive professionals: though such healthcare providers may not be impaired personally, the effects of their behaviors may (and often do) negatively affect the safety and efficacy of their colleagues performance. So while the disruptive physician may be assessed as being fit, her disruptive behavior may still pose significant problems to the overall functioning of the work environment including compromising patient safety.

Marty Martin, a former Hopkins guy (I think we only briefly overlapped our tenures there), wrote a nice little piece entitled, Taming Disruptive Behavior for the AGProfessional website. As you can see the concepts we talk about regarding disruptive behavior and disruptive professionals applies as much to agricultural professionals as it does to healthcare, legal or other “white collar” professionals.

The ApA put out a brief about a study published in Comprehensive Psychiatry which noted correlations between aggressive behavior and being fired from jobs. The brief nicely noted that people who self-describe as frequently engaging in aggressive behaviors (disruptive behaviors) are fired more often than their non-aggressive peers. However I didn’t like that the next paragraph mentioned intermittent explosive disorder, as this is a relatively rare disorder and in all my years of working with disruptive professionals (and workplace violence risk assessment), I have seen only a handful of cases of intermittent explosive disorder.

It has long been understood that bullies typically have been bullied themselves. A few months ago I came across an interesting write up about the correlation between bullying behavior (and victimization from such behavior) and psychiatric illness. In a study published in JAMA Psychiatry “researchers have found that elevated risk of psychiatric trouble extends into adulthood, sometimes even a decade after the intimidation has ended.” This is likely directly relevant for many disruptive professionals.

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